The Health System of Brazil

Social and Political Context

Naomar de Almeida Filho
Universidade Federal da Bahia

Instituto de Sade Coletiva

Economic & political background 1964-1985 Military dictatorship US dependent foreign policy External debt (economic miracle) Political repression National security ideology

Economic & political background 1986-2002 1988 New Constitution Hyperinflation & recession External debt crisis Political freedom Neoliberal ideology Economic inequality

Economic & political background 2003-present Reconstruction of the State Economic growth Technological dependency Independent foreign policy Expanded public policies Social inclusion

Social Context
Poverty reduction Environmental challenges Dilemmas in the labor context Violence and intolerance Reduction of inequalities Increasing social inequities

55.2 54.8

53.4

Gini coefficient trend. Brazil, 1995-2006-2011

53.0 52.4

Source: Brazil - IPEA; other countries - Central Intelligence Agency's World Factbook

Political Context
Reconstruction of the State:
Debate public vs. private Rhetorical intersectoriality Late expansion of public policies Fight against corruption Reforms com-promised Ideological regression

Health inequalities (update)

The life expectancy of Brazilian citizens reached 73.5 years in 2010, up 8.5 percent from 67 years in 1991, according to the Brazilian Institute of Geography and Statistics (IBGE) Among women, life expectancy reached 77.4 years in 2007, from 70.9 years in 1991 life expectancy of Brazilian men increased from 63.2 to 69.8 years in the same period

Health inequalities (update)

Brazil's infant mortality rate dropped to 21.6 deaths for every 1,000 live births in 2010, a 46 % decrease from the 45.1 deaths per 1,000 births in 1991. Regional differences in infant mortality rates remain high. The northeastern region, the poorest in Brazil, registered an infant mortality rate of 35.6 deaths per 1,000 living births; in the southern region, the rate was 16.1/1,000 births.

Brief History of Brazils Health Reform (1988-2009)

1986 8th National Health Conference 1988 The New Constitution 1990 The SUS Law (Unified Health System) 1992 Community Health Agents Program 1996-2000 The Family Health Program 2000-2007 Budget increase (CPMF) 2008-present: Overcoming

inequities

SUS structure (highlights)

Family Health Program (PSF)
Primary Health Care / health promotion Community Health Agents (> 200,000) multi-professional health teams (> 60,000)

Special Programs
HIV/AIDS Epidemiological Surveillance Pharmaceutical Care

High Complexity Care Management Pro-Sade (health professions training program)

SUS structure (highlights)

Social control (tripartite)
Local & regional Health Councils State Health Council National Health Council

Financing
Federal to municipality (fund to fund) State budget - High Complexity Municipality (PHC)

Accountability
TCU + CGU + DENASUS system State & Municipality auditing

Brasil health care system (diagram)

Primary HC Community Health Agents Secondary HC UPAs Health Centers CAPS SAMU
SUS-contracted services

Tertiary HC University Hospitals Public Hospitals

Family Health Teams

&

SUS-contracted Hospitals

health insurance general clinics

Out of pocket care

Private clinics

private hospitals

Coverage trend at municipal level

1998 1999 2000 2001 2002

Family Health Program

2003

2004

2005

2006

0%

1 to 25%

25 to50%

50 to 75%

75 to 100%

FONTE: SIAB - Sistema de Informao da Ateno Bsica

FHP Teams and Community Health Agents Brazil, 2010

FHT/CHA/OH FHS/CHA CHA without ESF, ACS E ESB

ESF 29.149 municipalities - 5.233 ACS 228.412 municipalities - 5.350 ESB 17.588 municipalities 4.567

Family Health Program

Effectiveness at municipal level

longitudinal ecological analysis using panel data from secondary sources. Analyses controlled for state level measurements of access to clean water and sanitation, average income, women literacy and fertility, physicians and nurses per 10,000 population, and hospital beds per 1,000 population.

10% increase in FHT coverage resulted in 4,6% decrease in infant mortality

Setting: 13 years (1990-2002) data from 26 Brazilian States and Federal District

Percentuais de variao da mortalidade infantil associados a 10% de incremento na cobertura da Sade da Famlia, de acesso a gua e de leitos hospitalares por mil habitantes. Brasil, 1990-2002
0,00 Sade da Famlia -0,50 -1,00 Acesso a gua Leitos hospitalares

% variao da mortalidade infantil

-1,50 -2,00 -2,50 -3,00 -3,50 -4,00 -4,50 -4,56 -5,00

-1,35

-2,92

Some data on SUS

80% of population depend on SUS 30% of population have health insurance / medical service plans 7,000 hospitals 70,000 health establishments 29,000 Family Health teams

Some data on SUS

2.3 billion clinical procedures 300 million medical consultations 11.3 million hospitalizations 15,000 organ transplants

SUS challenges:
Integrality Universal Access Management Social Value

Quality care
Financial stability

Dynamics of SUS-induced inequality

Complex regressive tax system biased

financial instability

of health workforce

education

quality
integrality
failure of

unequal

Social Value

low

access

unequal

social inequality

Thought-provoking question:
How to share Brazils 20-year experience in building a universal-access, statefunded, socially controlled Health System mostly in contradiction to the context of social inequality we live in?